Auricular nerve stimulation to address patient disorders, and associated systems and methods

ABSTRACT

Auricular nerve stimulation techniques for addressing patient disorders, and associated systems and methods. A representative system includes a signal generator having instructions to generate an electrical therapy signal, at least a portion of the electrical therapy signal having a frequency at or above the patient&#39;s auditory frequency limit, an amplitude in an amplitude range from about 0.1 mA to about 10 mA, and a pulse width in a pulse width range from 5 microseconds to 30 microseconds. The system further includes at least one earpiece having a contoured outer surface shaped to fit against the skin of the patient&#39;s external ear, external ear canal, or both, the at least one earpiece carrying at least two transcutaneous electrodes positioned to be in electrical communication with the auricular innervation of the patient, e.g., the auricular vagal nerve.

CROSS-REFERENCE TO RELATED APPLICATIONS

The present application is a continuation application of U.S.application Ser. No. 16/581,139, filed Sep. 24, 2019, which claimspriority to the following U.S. Provisional Applications 62/735,492,filed on Sep. 24, 2018; 62/785,205, filed on Dec. 26, 2018; and62/891,203, filed on Aug. 23, 2019. Each of the foregoing applicationsis incorporated herein in its entirety by reference.

TECHNICAL FIELD

The present technology is directed generally to auricular nervestimulation techniques for addressing patient disorders, and associatedsystems and methods.

BACKGROUND

Electrical energy application (“electrical stimulation”) to nerves orother neural tissue for the treatment of medical conditions has beenused for many decades. Cardiac pacemakers are one of the earliest andmost widespread examples of electrical stimulation to treat medicalconditions, with wearable pacemakers dating from the late 1950s andearly 1960s. In addition, electrical stimulation has been applied to thespinal cord and peripheral nerves, including the vagal nerve. Morespecifically, electrical stimulation has been applied transcutaneouslyto the vagal nerves to address various patient indications. While suchstimulation has provided successful patient outcomes in at least someinstances, there remains a need for improved systems for delivery oftranscutaneous vagus nerve stimulation that are compact, light,comfortable for the patient, without stimulation-induced perceptions,consistently positionable in the same location, and able to consistentlydeliver electrical current over a relatively wide area to accommodateanatomical differences.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a partially schematic side view of a human ear, illustrating arepresentative target region for stimulation in accordance withembodiments of the present technology.

FIG. 2 is a partially schematic illustration of a system havingearpieces, a signal generator, and an external controller arranged inaccordance with representative embodiments of the present technology.

FIGS. 3A and 3B illustrate an earpiece having electrodes positioned toapply stimulation in a clinical setting, in accordance withrepresentative embodiments of the present technology.

FIG. 4 is a partially schematic illustration of a system having a signalgenerator positioned within a housing that fits around the patient'sneck, in accordance with embodiments of the present technology.

FIGS. 5A and 5B are further illustrations of portions of therepresentative system shown in FIG. 4.

FIGS. 6A and 6B are partially schematic isometric illustrations of anearpiece carrying two electrodes in accordance with representativeembodiments of the present technology.

FIG. 7 is a partially schematic illustration of an earpiece thatincludes custom-fit components in accordance with embodiments of thepresent technology.

FIGS. 8A and 8B are partially schematic rear and side views,respectively, of a system having a signal generator integrated with twoearpieces, in accordance with representative embodiments of the presenttechnology.

FIGS. 9A and 9B illustrate a system that includes multiple earpieces,each with an integrated signal generator, in accordance with embodimentsof the present technology.

FIGS. 10A-10C illustrate a technique for manufacturing an electrode toprovide auricular stimulation in accordance with representativeembodiments of the present technology.

FIGS. 11A-11C illustrate a representative technique for manufacturinglarger volumes of electrodes in accordance with representativeembodiments of the present technology.

FIG. 12 is a schematic illustration of a representative wave form inaccordance with embodiments of the present technology.

FIGS. 13 and 14 illustrate representative clinical processes fordemonstrating use of the stimulation devices configured in accordancewith embodiments of the present technology.

DETAILED DESCRIPTION

General aspects of the anatomical and physiological environment in whichthe disclosed technology operates are described under Heading 1.0(“Introduction”) below. Definitions of selected terms are provided underHeading 2.0 (“Definitions”). Representative treatment systems and theircharacteristics are described under Heading 3.0 (“RepresentativeSystems”). Representative signal delivery parameters are described underHeading 4.0, representative indications and effects are described underHeading 5.0, representative clinical evaluations are described underHeading 6.0, representative pharmacological supplements are describedunder Heading 7.0, and further representative embodiments are describedunder Heading 8.0.

1.0 Introduction

The present technology is directed generally to auricular nervestimulation to address patient disorders, and associated systems andmethods. In particular embodiments, electrical signals are delivered tothe auricular branches of the vagal nerve transcutaneously to addressany of a variety of patient disorders, including for, example rheumatoidarthritis, migraine headache, and asthma. Further disorders treatable bythese techniques are described later herein. The electrical signals aregenerally provided at frequencies ranging from about 15 kHz to about 50kHz. In particular embodiments, the frequency of the signal is selectedto be above the patient's auditory limit, so as to avoid inducingpotentially unwanted side effects via the patient's hearing faculties.In further representative embodiments the physiological location towhich the electrical signals are delivered is deliberately selected togenerate primarily or exclusively afferent signals. Accordingly, theeffect of the stimulation can be limited to reducing the effects and/orthe underlying causes of the patient disorder, via stimulation thattargets particular brain regions, without the signals inadvertentlystimulating other (e.g., peripheral) nerves of the patient.

2.0 Definitions

Unless otherwise stated, the terms “about” and “approximately” refer tovalues within 20% of a stated value.

As used herein, and unless otherwise noted, the terms “modulate,”“modulation,” “stimulate,” and “stimulation” refer generally to signalsthat have an inhibitory, excitatory, and/or other effect on a targetneural population. Accordingly, a “stimulator,” “electrical stimulation”and “electrical therapy signals” can have any of the foregoing effectson certain neural populations, via electrical communication (e.g.,interaction) with the target neural population(s).

As used herein, the term “auricular nerve” includes the auricular branchof the vagal nerve (sometimes referred to as Arnold's nerve or aVN), aswell as other auricular nerves, for example, the greater auricularnerve, and/or the trigeminal nerve.

The term “therapeutically-effective amount,” as used herein, refers tothe amount of a biologically active agent needed to initiate and/ormaintain the desired beneficial result. The amount of the biologicallyactive agent employed will be that amount necessary to achieve thedesired result. In practice, this will vary widely depending upon theparticular biologically active agent being delivered, the site ofdelivery, and the dissolution and release kinetics for delivery of thebiologically active agent (including whether the agent is deliveredtopically, orally, and/or in another manner), and the patient'sindividual response to dosing.

The term “paresthesia” refers generally to an induced sensation ofnumbness, tingling, prickling (“pins and needles”), burning, skincrawling, and/or itchiness.

Several aspects of the technology are embodied in computing devices,e.g., programmed/programmable pulse generators, controllers and/or otherdevices. The computing devices on/in which the described technology canbe implemented may include one or more central processing units, memory,input devices (e.g., input ports), output devices (e.g., displaydevices), storage devices, and network devices (e.g., networkinterfaces). The memory and storage devices are computer-readable mediathat may store instructions that implement the technology. In someembodiments, the computer- (or machine-) readable media are tangiblemedia. In some embodiments, the data structures and message structuresmay be stored or transmitted via an intangible data transmission medium,such as a signal on a communications link. Various suitablecommunications links may be used, including but not limited to a localarea network and/or a wide-area network.

3.0 Representative Systems

Representative systems in accordance with the present technology deliverelectrical signals transcutaneously to the auricular branch(es) of apatient's vagus nerve. The signals are delivered via electrodespositioned at or partially within one or both of the patient's ears.FIG. 1 illustrates the general physiology of the external portion of ahuman ear 180, indicating a representative target region 195 at whichthe electrical signals are applied. The external ear 180 includes thehelix 181 partially encircling the triangular fossa 182 and the scaphoidfossa 184, and terminating at the lobule or lobe 190. Within the helix181 is positioned the antihelix 185, the antihelix crura 183, theantitragus 188, and the intertragic notch 189. The concha 191 ispositioned inwardly from the antihelix 185, and includes the cymbaconcha 192 and cavum concha 193, bounded by the tragus 187 and separatedfrom the cymba concha 192 by the helix crus 186. The skin 196 of theexternal ear 180 extends into the external ear canal 194, whichterminates at the ear drum (not visible in FIG. 1). The auricular branchof the vagus nerve 197 innervates the ear 180, and the target region 195is generally over and/or adjacent the auricular branch 197.

As shown in FIG. 1, the target region 195 is positioned primarily at theconcha 191 and can extend at least partially into the ear canal 194.Devices configured in accordance with embodiments of the presenttechnology are configured not only to deliver electrical therapy signalsto the target region 195, but to provide a comfortable, repeatable, andin at least some embodiments, patient-specific, structures and therapysignals for doing so.

FIG. 2 is a partially schematic illustration of a representative system100 for transcutaneously delivering electrical therapy signals to theauricular branches of the patient's vagus nerves, in accordance withrepresentative embodiments of the present technology. The system 100includes a signal generator 110 coupled to one or more earpieces 120(shown as a left earpiece 120 a and a right earpiece 120 b), and anexternal controller 130. The signal generator 110 can include a housing111 that encloses or partially encloses signal generating circuitry 114.The signal generating circuitry 114 can be controlled by an internalcontroller 108, e.g., a processor 113 that accesses instructions storedin a memory 112. The signal generator 110 can include a signaltransmission port 115 for communicating with the earpieces 120, e.g.,transmitting an electrical therapy signal to the earpieces 120, andoptionally, receiving feedback or other communications from theearpieces 120. When the system 100 is in use, the electrical therapysignal is in electrical communication with the target neural populationto create a desired effect on the target neural population. Acommunications transceiver 116 provides for communication between thesignal generator 110 and the external controller 130.

The earpieces 120 can be coupled to the signal generator 110 via one ormore earpiece links 121. In particular embodiments, the earpiece link121 includes a wired link e.g., a cable or other elongated conductor. Inother embodiments, the earpiece link 121 can include a wirelessconnection. The earpiece link or links 121 can be connected to each ofthe earpieces 120 to provide the same input to each, or differentiatedinputs to each. The earpiece link(s) 121 can also direct communications(e.g., patient data) back to the signal generator 110, e.g., fromsensors carried by the earpieces 120.

The signal generator 110 can be configured to rest on any suitablesurface (e.g., a table top), or can be carried by the patient in thepatient's hand or in a holster or in another suitable manner. The signalgenerator 110 can be powered by a power source 117, e.g., one or morebatteries (e.g., rechargeable batteries) and/or an external powersource. In particular embodiments, the signal generator 110 iscontrolled by the external controller 130 via a controller link 132. Theexternal controller 130 can include a cellular phone or other mobiledevice (e.g., a smartwatch), and can access a specific phone-based app131 to provide controls to the signal generator 110. In operation, aphysician or other suitable practitioner can set the stimulationparameters at the signal generator 110 via the external controller 130,and the patient and/or the practitioner can update the signal deliveryparameters via the same or a different external controller 130. In someembodiments, the practitioner may have control over more parameters thanthe patient does, for example, to better control possible patientoutcomes. The practitioner (and/or others) may direct or otherwiseaffect the internal controller 108 remotely via the external controller130 and/or other devices, e.g., a backend device as described furtherwith reference to FIG. 4.

FIGS. 3A and 3B illustrate a representative earpiece 320 by itself (FIG.3A) and in position on the patient's ear 180 (FIG. 3B). With referencefirst to FIG. 3A, the earpiece 320 includes two electrodes 322, and anearpiece link 321 for communication with the associated signalgenerator. The two electrodes 322 are positioned to provide atranscutaneous, bipolar signal to the patient's ear.

Referring next to FIG. 3B, the earpiece 320 is positioned at thepatient's ear 180, with a portion of the earpiece 320 extending behindthe helix 181 for support, and with the electrodes 322 positioned at thetarget region 195, e.g., against the patient's skin 196 at the concha191. This positioning has been demonstrated in a clinical setting toprovide effective therapy for the patient. As discussed further below,other earpiece configurations can provide additional positioningprecision and/or patient comfort.

FIG. 4 is a partially schematic illustration of a representative system400 configured in accordance with the present technology. The system 400includes a signal generator 410 that has a generally horseshoe-shapedhousing 411 so as to fit comfortably around the patient's neck when inuse, and may accordingly be referred to herein as a neckpiece. Thehousing 411 can in turn include the internal components described abovewith reference to FIG. 2. Two earpiece links 421 (e.g., in the form offlexible cables) connect the signal generator 410 to correspondingearpieces 420 a, 420 b, which each carry two electrodes 422. The signalgenerator 410 can be controlled by an external controller 430 via awireless controller link 432. The external controller 430 canaccordingly be used to set and/or adjust the signal delivery parametersin accordance with which the signal generator 410 provides therapeuticelectrical signals to the earpieces 420.

The external controller 430 can also communicate with a backend device440 (e.g., a server or other suitable device located on the cloud orother medium) via a backend link 441. Accordingly, the externalcontroller 430 can exchange data with the backend 440. For example, theexternal controller 430 can provide the backend 440 with informationabout the patient's condition (e.g., obtained from feedback sensorsincluded in the system 400), and/or a schedule of the signal deliveryparameters selected by the patient or practitioner over the course oftime. In addition, (or alternatively), the backend 440 can be used toprovide updates to the phone-based app or other software contained onthe external controller 430. The allocation of processing tasks and/ordata storage between the internal controller 108 (FIG. 2), the externalcontroller 430 and the backend 440 can be selected to suit thepreferences of the patient, practitioner, and/or others.

FIGS. 5A and 5B further illustrate features of the system 400 describedabove with reference to FIG. 4. In particular, FIG. 5A illustrates thesignal generator 410 as including an input device 418 and an outputdevice 419. The input device 418 can include a button or other elementto activate or deactivate the signal generator 410. The output device419 can include an LED or other element to indicate when the signalgenerator 410 is on. In other embodiments, the input device 418 and/orthe output device 419 can be used to perform other suitable functions.For example, the output device 419 can provide an audible tone or otheralert if the earpiece(s) 120 are not correctly positioned. The inputdevice 418 can accept user inputs (as described above), or can be asensor, e.g., a proximity sensor that detects contact with the patient'sskin, via an impedance measurement or otherwise and is coupled to theoutput device 419 to provide the alert. The frequency of the alert tonecan be patient-specific because, as described later, different patientsmay have different hearing ranges.

FIG. 5B schematically illustrates a portion of the signal generator 410,with part of the housing 411 cut away to illustrate a printed circuitboard 409. The printed circuit board 409 can carry the internalcomponents described above with reference to FIG. 2, and is coupled tothe earpiece link 421.

FIGS. 6A and 6B illustrate front and rear views, respectively, of arepresentative earpiece 620 configured to fit a variety of patientphysiologies. The earpiece 620 includes two electrodes 622 positioned toprovide transcutaneous stimulation to the target region 195 (FIG. 1). Inaddition, the earpiece 620 includes features configured to provide forpatient comfort and to securely, yet removably, keep the electrodes 622in position at the target region. For example, the earpiece 620 caninclude a bulging, flexible portion 670 that provides for snug contactbetween the electrodes 622 and the patient's skin at the target region.This approach can make device placement more consistent and repeatableacross a patient population.

The earpieces shown in FIGS. 6A and 6B, as well as elsewhere herein, maybe fungible items that are replaced periodically due to normal wear.Accordingly, the earpieces can be configured to separate from the restof the system for replacement.

FIG. 7 illustrates another representative earpiece 720 having electrodes722. As shown in FIG. 7, the electrodes 722 can have a shape other thanthe circular shape shown in FIGS. 6A and 6B. For example, the electrodes722 can have a rectangular shape. In other embodiments, the electrode722 can have an ovoid shape or other shape that is specific to one ormore patients, e.g., based on patient physiology.

In at least some embodiments, the earpiece 720 shown in FIG. 7 can becustom-made to fit a particular patient. For example, comparing theearpiece 720 shown in FIG. 7 with the earpiece 620 shown in FIG. 6A, itis evident that the flexible portion 770 of the custom-made earpiece 720is larger and bulges outwardly more than the corresponding flexibleportion 670 shown in FIG. 6A. The custom earpiece 720 can accordinglyfit better in the particular patient's ear. Representative techniquesfor forming the earpiece 720 can include making a mold of the patient'sear and, for at least a portion of the earpiece, duplicating thecontours of the mold so as to fit in the patient's ear. In otherembodiments, many of the processes can be performed digitally, e.g.,using 3-D imaging techniques to identify the contours of the patient'sear, and 3-D additive manufacturing techniques or computer-controlledsubtractive manufacturing techniques to form the earpiece contours. Theearpiece may be constructed from materials that are soft and moldable(e.g., 10-60 on the Shore A hardness scale). Accordingly, the earpiececan form a tight and/or “snug” fit in the patient's ear to position theelectrodes at the target region (e.g., the concha, and in particularcases, the cymba concha). In some embodiments, the custom fit may beachieved via moldable plastic materials. In other embodiments, thecustom fit may be achieved by the use of materials with appropriatestickiness of tackiness that can mold to and remain tightly and snug onthe outer area of the patient's ear and target the concha without thediscomfort or suboptimal connections found in devices that can only besecured by entering the ear canal. The conformal nature of the earpiececan produce an electrode-to-skin contact area in a range of from 20% to100% of the exposed electrode surface area. This intimate contact canfurther reduce the likelihood for generating paresthesia, because lessenergy is required to be delivered to the electrode to achieve atherapeutic effect.

An advantage of a custom earpiece is that it is likely to be morecomfortable and/or provide more effective therapy than a standard-sizeearpiece. Conversely, the standard-sized earpiece is likely to be lessexpensive to manufacture. Accordingly, in some instances, patients andpractitioners can use standard earpieces where practical, and customearpieces as needed.

FIGS. 8A and 8B illustrate another representative system 800 having asignal generator 810, earpieces 820 a, 820 b, and earpiece links 821,all of which are integrated to provide a unitary, single-piece device.For example, the signal generator 810 can include a housing 811 thathouses the earpiece links 821 (in addition to the signal generatingcircuitry), and directly supports the earpieces 820 a, 820 b. Inparticular embodiments, the earpieces 820 a, 820 b can be removable fromthe housing 811 for periodic replacement (as discussed above), but thehousing 811 can nevertheless provide a more robust support for theearpieces than the flexible cable described above with reference to FIG.2. Whether the patient uses a one-piece configuration as shown in FIGS.8A and 8B, or other configurations shown herein, can depend on patientpreferences, and the degree to which the system provides consistent,effective treatment for the particular patient.

FIGS. 9A and 9B illustrate a further representative system 900 in whichthe signal generator 910 is integrated with the earpiece 920 in a singlehousing 911. Beginning with FIG. 9A, for patients using multipleearpieces (as is typical), each earpiece includes a dedicated signalgenerator 910. In at least some embodiments, the signal generators 910can communicate with each other (e.g., wirelessly) to provide forconsistent treatment. An advantage of the approach shown in FIG. 9A isthat it may be more comfortable and/or less cumbersome than devices thathave the signal generators positioned some distance away from theearpieces. Conversely, devices with the signal generator positioned awayfrom the earpieces may provide more stability for the earpieces, and/orincreased patient comfort.

FIG. 9B illustrates a representative charging station 950 for chargingthe signal generator 910 shown in FIG. 9A. The charging station 950 caninclude a base 952 having multiple ports 951 (e.g., one port for eachearpiece 920) and an optional cover 953 to protect the earpieces 920during charging. The earpieces 920 can be charged inductively so as toavoid the need for direct mechanical contact between electrical elementsof the signal generator 910 and electrical elements of the chargingstation 950. The charging station 950 itself can receive power via aconventional wall outlet, battery, and/or other suitable source.

FIGS. 10A-10C illustrate a representative technique for manufacturingelectrodes in accordance with embodiments of the present technology.Referring first to FIGS. 10A and 10B a representative electrode 1022includes a backing 1023, e.g., a fabric and/or textile with an acrylicadhesive, and/or a non-fabric (e.g., vinyl). The earpiece link 1021 caninclude an insulated conductive wire with individual wire strands 1024that are spread apart and placed against the backing 1023. Optionallyadditional adhesive 1026 is then used to secure the wire strands 1024and backing 1023 to a conductive material 1025 (removed in FIG. 10B)that contacts the patient's skin.

FIG. 10C is a partially schematic, cut-away illustration of theelectrode 1022 illustrating the sandwich construction of the backing1023, the wire strands 1024, and the conductive material 1025. Inparticular embodiments, the conductive material 1025 can include aconductive silicone and/or other polymer (e.g., a silicone impregnatedwith one or more conductive materials), which is comfortable to placeagainst the patient's skin 196. During use, the practitioner or patientcan brush an electrically conductive solution 1029 on the conductivematerial 1025. The solution need not be adhesive because the force usedto keep the electrode 1022 in place is a mechanical force provided byother portions of the earpiece structure, which are in contact with thepatient's skin. The conductive material 1025 can be roughened orotherwise textured so as to retain the solution 1029 for the duration ofa treatment period. As discussed in further detail below under Heading4.0, individual treatment periods are relatively short in duration.

In certain embodiments, the foregoing electrode design and productionprocess allows a user (patient and/or practitioner) to adjust thesurface properties to help better retain the solution 1029 between theelectrode 1022 and the skin surface (e.g., via roughening, as describedabove). Further, the design can facilitate tuning the impedance acrossthe electrode surface by arranging the conductor wires (e.g., formedfrom metal or carbon) in certain shapes. The electrodes described hereinmay also be designed to reduce current “hotspots” by features in themold. In some embodiments, the electrode together with the earpiecehousing or enclosure can include a built-in mechanism to apply thesolution 1029 on the electrode surface before and/or after each use.

The earpiece as a whole can also maintain intimate contact with the skinat its functional surfaces by using features of the patient's ear as alever, for example, providing intimate electrical contact at the cymbaconcha by pushing off the inside of the antitragus, or via alignmentwith the ear canal.

FIGS. 11A-11C illustrate a technique for larger scale production of theelectrodes 1022. FIGS. 11A-11C illustrate top, bottom andcross-sectional views, respectively, of an intermediate stage ofproduction in which the conductive material 1025 is positioned against alayer of foil 1027 (not visible in FIG. 11A) so that portions of theconductive material 1025 project through openings 1028 to hold theconductive material 1025 in place. The foil 1027 provides an electricalpath to the electrodes 1022. In this embodiment, six (rectangular)electrodes are formed together and then separated prior to installationon corresponding earpieces.

4.0 Representative Signal Delivery Parameters

The representative systems described above deliver electrical signals tothe patient in accordance with selected signal delivery parameters. Thesignal delivery parameters can include the characteristics defining ordescribing the signal, and the location to which the signal isdelivered. In general, the signal is biphasic and is applied at afrequency in a range of about 15 kHz to about 50 kHz. FIG. 12 is aschematic illustration of a representative signal 1260. The signal(e.g., the signal wave form) includes anodic pulses 1261 and cathodicpulses 1262 separated by an interphase spacing 1264. Individual pairs ofanodic and cathodic pulses 1261, 1262 can be separated from neighboringpairs by an interpulse spacing 1265. Each pulse can have a pulse width1263, which can be the same for anodic pulses 1261 as for cathodicpulses 1262, or different, depending upon the embodiment. The repeatingperiod of the signal 1266 is made up of the anodic pulse 1261, thecathodic pulse 1262, the interphase spacing 1264, and the interpulsespacing 1265. The inverse of the period 1266 corresponds to thefrequency of the signal.

In representative embodiments, at least a portion of the signal 1260 hassignal delivery parameters in the following ranges:

-   -   Frequency: about 15 kHz to about 50 kHz, or about 20 kHz to        about 50 kHz or 20 kHz    -   Amplitude: about 0.1 mA to about 10 mA, or about 1 mA to about 5        mA, or about 2 mA to about 4 mA    -   Pulse width: about 5 microseconds to about 30 microseconds,        e.g., about 20 microseconds    -   Interphase spacing: about one to about 10 microseconds    -   Interpulse spacing: about one to about 15 microseconds    -   Duty cycle: on-period of 0.1 seconds—15 minutes        -   off-period of 0.1 seconds—15 minutes

In some embodiments, the signal 1260 (e.g., the values of the foregoingparameters) remain constant for the duration that the signal isdelivered. In other embodiments, one or all of the foregoing parameterscan vary, with the average value remaining in the foregoing ranges. Forexample, the frequency can be varied, while the average frequencyremains within the foregoing range of about 15 kHz to about 50 kHz.Representative varying waveforms include Gaussian and/other non-linearwaveforms. The average frequency corresponds to the inverse of theaverage period of the signal taken over multiple periods. As describedabove, an individual period is the sum of the anodic pulse width (e.g.,a first pulse width), the cathodic pulse width (e.g., a second pulsewidth) of a neighboring pulse, the interphase spacing, and theinterpulse spacing.

As described herein, at least a portion of the signal has parameterswithin the foregoing ranges. Accordingly, in some embodiments, thesignal may deviate from the foregoing ranges so long as doing so doesnot significantly impact the efficacy of the therapy and/or the comfortof the patient.

The electrical therapy signal is typically delivered to the patient overthe course of one or more sessions that have a limited duration. Forexample, an individual session typically lasts no longer than sixtyminutes and is typically at least two seconds in duration. In moreparticular embodiments, the duration ranges from about two seconds toabout thirty minutes, and in a further particular embodiment, theduration is from five minutes to twenty minutes, or about fifteenminutes. The patient can receive treatment sessions at most once perday, at most twice per day, or at other suitable intervals, depending,for example, on the patient's response to the therapy. In arepresentative embodiment, the patient receives therapy in two 15 minutesessions, spaced apart by about 12 hours.

It is expected that electrical therapy signals having parameters in theforegoing ranges will provide effective therapy to the patient, withoutcausing paresthesia and/or other potentially undesirable sensoryresponses in the patient. Accordingly, the electrical therapy signal maybe referred to herein as a non-sensory response therapy signal.Undesirable sensory responses include, in addition to or in lieu ofparesthesia, a sensation of heat and/or pressure, and/or side effectsrelated to the patient's hearing faculties. In particular, the frequencyof the signal can be deliberately selected to be above the patient'supper hearing threshold. While it is not believed that the therapysignal generates sound waves, it may nevertheless trigger an auditoryresponse, e.g., a sensation of “ringing,” possibly through mechanical,bone, and/or far-field electrical conduction, and/or interactions withnative mechanical acoustic damping systems, e.g., the tensor tympanimuscle. The typical upper hearing threshold for a patient is at or below15 kHz and accordingly, a signal having a frequency in the range ofabout 15 kHz to about 50 kHz can provide paresthesia-free stimulation,without triggering auditory effects. Because the upper threshold differsfrom patient to patient, the signal frequency can be selected on apatient-by-patient basis. For example, patients having a reduced upperthreshold (e.g., older patients) can potentially receive a beneficialeffect from stimulation toward the lower end of the above frequencyrange, or even below the above frequency range. The patient's upperauditory threshold may change over time. By customizing the frequency toan individual patient, a wider range of frequencies are available to thepractitioner. In addition, lower frequencies may consume less power,which can in turn allow the device applying the stimulation to besmaller, and/or to undergo fewer recharging cycles.

As discussed above, the electrodes applying the stimulation arepositioned to target the auricular branches of the patient's vagalnerve. It is expected that, by targeting the auricular branches, theeffect of the signals will be limited to an afferent effect (e.g.,affecting the brain) and not an efferent effect (e.g., affecting otherperipheral nerves). An advantage of this arrangement is that thelikelihood for inducing unwanted side effects is limited, and instead,the stimulation is focused on producing an effect on the patient's brainto provide a therapeutic result.

5.0 Representative Indications and Effects

Embodiments of the present technology are suitable for treating avariety of patient indications. Representative indications include: (1)inflammatory indications (e.g., arthritis, rheumatoid arthritis,fibromyalgia, irritable bowel syndrome, Crohn's disease, asthma,psoriasis, Sjogren's Syndrome, autoimmune nephropathy (e.g. Berger'sIgA), sepsis, and lupus); (2) neurological indications (e.g.,depression, post-partum depression, Alzheimer's disease, migraine,headaches, cluster headaches, epilepsy, and mood disorders); (3)sleep-related indications (e.g., insomnia, failure to achieve deepsleep, REM sleep behavior disorder, and parasomnia; (4) functionalenhancement (e.g., memory enhancement, associative learning); and/or (5)pulmonary dysfunctions (asthma, allergic rhinitis, allergic bronchitis,exercise induced bronchoconstriction).

Without bound by theory, it is believed that the efficacy of thepresently disclosed therapeutic technique may be correlated with changesin the brain's functioning. In particular, it is expected thatnetworking and/or connectivity between areas of the brain will improveor revert to normal as a result of the therapy. Representative affectedareas of the brain may include the insular cortex, the cingulate, thehypothalamus, subsets of the thalamic nuclear complex, the amygdalacomplex, bed nucleus of the stria terminalis, medial temporal lobe(hippocampus, parahippocampal gyrus and entorhinal cortex), elements ofthe basal ganglia (putamen, globus pallidus, caudate nucleus) and/or theprefrontal and/or orbital frontal cortex. Such results may bedemonstrated by functional magnetic resonance imaging (fMRI) and/orsuitable techniques. It is further believed that the electrical therapysignal may reduce at least one pro-inflammatory marker and/or increaseat least one anti-inflammatory biomarker. Representativepro-inflammatory biomarkers include IL-1, IL-6, IL-12, IL-17, IL-18,C-reactive protein, TNF-α, and INF-γ. Representative anti-inflammatorybiomarkers include IL-4, IL-10, IL-13, IFN-α, and TGF-β. The biomarkerscan be assessed as part of the patient screening process, and/or at anypoint during the therapy regimen, described further below with referenceto FIGS. 13 and 14.

As discussed above, one feature of embodiments of the current technologyis that the electrical therapy signal does not generate paresthesia inthe patient. Paresthesia can contaminate the benefits ofneurostimulation by causing competing brain signals that detract fromthe desired therapeutic effects. This may occur in part becauseparesthesia introduces confounding information in neuroimaging analysissuch as functional magnetic resonance imaging andelectroencephalography. Paresthesia-inducing stimulation modulatessomatosensory neural circuits instead of solely targeting vagal neuralcircuits, which limits the interpretation of neuroimaging results. Forexample, modulation of the insula (a cortical region) is commonly citedas biomarker for vagus nerve stimulation efficacy. However, the insulais also implicated in pain/noxious stimulus processing and can bemodulated via somatosensory pathways. Accordingly, paresthesia-inducingstimulation can have a contaminating and/or contra-indicated impact. Asa result, eliminating paresthesia from the treatment regimen can improvenot only patient comfort and willingness to engage in the therapy, butalso the ability of the practitioner to assess the efficacy of thetherapy and make adjustment.

6.0 Representative Clinical Evaluations

Vorso Corp., the assignee of the present application, is currentlyconducting multiple prospective, multi-center pilot studies to researchthe safety, tolerability, and efficacy of devices configured inaccordance with the present technology. One study is directed topatients with moderate to severe active rheumatoid arthritis, as shownin FIG. 13, and another is directed to patients with episodic migraine,as shown in FIG. 14.

In FIGS. 13 and 14, the following acronyms are used:

-   -   DAS28-CRP (Disease Activity Score 28, using the C-Reactive        Protein)    -   ECG (electrocardiogram)    -   CRP (C-Reactive Protein)    -   MRI (Magnetic Resonance Imaging    -   HAQ-DI (Health Assessment Questionnaire Disability Index)    -   CK (creatine kinase)    -   RF (rheumatoid factor)    -   Anti-CCP (Anti-cyclic citrullinated peptide)

Referring first to FIG. 13, the clinical process 1300 includes anenrollment process 1301 (commencing about 35 days before treatment) anda screening process 1303 (starting at 8 days before treatment). At block1305, based on the enrollment and screening processes, patienteligibility is determined. The inclusion/exclusion criteria for patientsenrolled in the study are those who have inadequate response to DMARDs(disease-modifying anti-rheumatic drugs), and who fail one biologictreatment, or are biologic naive. The study commences (block 1307) witha number of patient metrics identified as a baseline. As indicated inFIG. 13, the metrics can include the patient's medication intake,DAS28-CRP score, the patient's sleep characteristics, HAQ-DI score, ACR,and blood characteristics (including CRP (C-reactive proteins),analytics, CK, RF, and anti-CCP). At block 1307, the patient is alsotrained to use the device.

The patient's progress is then tracked after one week (block 1309), twoweeks (block 1311), four weeks (block 1313), eight weeks, (block 1315),and twelve weeks (block 1317). At each of the foregoing blocks, thepatient metrics indicated in FIG. 13 are measured and tracked.

Early results from the study described in FIG. 13, based on changes intender/swollen joints, patient and physician assessment scores, MRIscores, ultrasound scores and HAQ-DI changes, indicate that the therapyis safe and effective in treating patients with moderate to severerheumatoid arthritis. The patients did not experience paresthesia orother sensory side effects. Accordingly, these preliminary results areencouraging.

Vorso Corp. is also conducting fMRI (functional MRI) studies and theearly results indicate that the therapy causes functional connectivitychanges in brain regions associated with the regulation of inflammation.

Referring now to FIG. 14, Vorso Corp. has also begun a study directed tosafety and efficacy of devices in accordance with the foregoingdescription applied to patients with episodic migraine. The objective ofthe study is to observe and evaluate the effect of the therapy onmigraine and/or associated symptoms, in subjects who suffer four tofourteen migraine days per month. As shown in FIG. 14, the clinicalprocess 1400 includes patient enrollment (block 1401), and eligibilitydetermination (block 1403), with the study commencing at block 1405. Theprimary metric during the study is the patient's migraine diary, inwhich the patient records migraine events. In this study, the patientundergoes a one-month baseline period, during which the patient tracksmigraine activity in the absence of an electrical therapy signal. Duringa follow-up visit (block 1407), the baseline diary recordings areevaluated and, using an ear mold, the patient is outfitted with a customearpiece, or two custom earpieces. At block 1409, the patient is trainedto use the device. The remaining processes include evaluation atperiodic intervals, including a one-month evaluation (block 1411), atwo-month evaluation via telephone (block 1413), a three-month diaryevaluation (block 1415), a four-month evaluation via telephone (block1417), a five-month evaluation via telephone (block 1419), and finalvisit at six months (block 1421) during which the patient's diaryevaluation is completed. Preliminary results are positive.

7.0 Representative Pharmacological/Biological Supplements

In at least some embodiments of the present technology, the foregoingelectrical therapy signal can be provided as part of an overalltreatment regimen that also includes administering apharmacological/biological substance to the patient. It is expected thatthe pharmacological/biological supplement will increase the efficacyand/or duration of the electrical therapy, and/or that the electricaltherapy can improve on the results obtained via a pharmacologicaltreatment. For example, the electrical therapy signal can improve thetherapeutic “window” for medication, which corresponds to the differencebetween efficacy and toxicity. Some of these pharmacological/biologicaldrugs have severe dose-depending effects and it is expected that theelectrical therapy can reduce the amount of drug needed by the patientand in effect limiting the side effects. In a representative example,the treatment regimen can include administering an effective amount of apharmaceutical selected from, but not limited to, the following groups

-   -   csDMARD (conventional synthetic disease modifying antirheumatic        arthritis drug) group including, but not limited to,        methotrexate, sulfasalazine, leflunomide, hydroxychloroquine,        gold salts;    -   bDMARD (biological disease modifying antirheumatic arthritis        drug) group including, but not limited to, abatacept,        adalimumab, anakinra, etanercept, golimumab, infliximab,        rituximab and tocilizumab;    -   tsDMARD (targeted synthetic disease modifying antirheumatic        arthritis drug) group including, but not limited to,        tofacitinib, baricitinib, filgotinib, peficitinib, decernotinib        and upadacitinib; and/or    -   CGRP (calcitonin gene-related peptide) inhibitor drug group        including, but not limited to, erenumab, fremanezumab,        galcanezumab and Eptinezumab.    -   Agents useful in the treatment of asthma include inhaled        corticosteroids, leukotriene modifiers, long-acting beta        agonists (LABAs), theophylline, short-acting beta agonists such        as albuterol, ipratropium (Atrovent®), intravenous        corticosteroids (for serious asthma attacks), allergy shots        (immunotherapy), and omalizumab (Xolair®).

8.0 Further Embodiments

From the foregoing, it will be appreciated that specific embodiments ofthe disclosed technology have been described herein for purposes ofillustration, but that various modifications may be made withoutdeviating from the technology. For example, embodiments of the earpiecesdescribed above include pairs of electrodes that deliver bipolarsignals. In other embodiments, an individual earpiece can include asingle, monopolar electrode, with a return electrode positioned remotelyfrom the earpiece, or the earpiece can include more than two electrodes.The neckpiece can have configurations other than those specificallyshown in the foregoing Figures. The amplitude at which the electricaltherapy signal is delivered can be provided in the form of a stepfunction that remains constant throughout the duration of the therapy,in some embodiments. In other embodiments, the amplitude of the signalcan be ramped up gradually (e.g., over multiple incremental steps), forexample, if the patient experiences sensory side effects, such asdiscomfort, when the amplitude is increased in a single step.

In addition to systems and methods for using and manufacturing suchsystems, the present technology includes methods for programming thesystems for use. For example, as discussed above, a physician or otherpractitioner (e.g., a company representative), can program some or allof the signal delivery parameters into the signal generator. As was alsodiscussed above, the patient may have the ability to modify at leastsome of the parameters, for example, via the external controller.

As discussed above, the communication pathways between the earpiece andthe signal generator, and between the signal generator and the externalcontroller can be in two directions. Accordingly, the signal generatorcan receive information from the earpieces and/or other elements of thesystem and take actions based on that information. In one representativeexample, the earpiece can include a proximity sensor that indicates ifthe earpiece becomes dislodged or mispositioned during a treatmentsession. The system can further include a small speaker or otherauditory feedback element that indicates to the patient that theposition of the earpiece should be adjusted. In another representativeexample, the external controller can track attributes of each treatmentsession, for example, the number of treatment sessions, the duration ofthe treatment sessions, the time of day of the treatment sessions and/orother data relevant to correlating the patient's response with theattributes of the treatment sessions. The system can include a wearablesignal generator, e.g., in the form of a neckpiece or integrated withthe earpieces (as described above), or in the form of a headband orother wearable. In a further example, the earpiece(s) can includespeakers to provide music and/or other audio input to the user (e.g.,via the external controller).

More generally, the system can include at least one sensor capable ofsensing a body signal. The sensor may be selected from, withoutlimitation, a cardiac sensor, a blood oxygenation sensor, acardiorespiratory sensor, a respiratory sensor, and a temperaturesensor. In one embodiment, the electrodes themselves can operate assensors to detect proximity to the patient's skin, and/or impedance. Oneor more processors of the system determine a body parameter based on thebody signal. For example, the processor can calculate a heart rate,heart rate variability, parasympathetic tone, sympathetic tone, orsympathetic-parasympathetic balance from a cardiac signal; a pulseoximetry value from a blood oxygenation signal; a breathing rate or endtidal volume from a respiratory signal; and/or a sleep and/or exertionallevel from an accelerometer, gyroscope and/or GPS device coupled to thepatient's body. The system can then use the body parameter to adjust oneor more parameters in accordance with which the electrical signal isdelivered (or not delivered). For example, the signal may be turned offif the patient's heart rate falls below a predetermined lower limit, orif activity levels become elevated or depressed. In a representativeembodiment, the sensor is located on the skin of a lateral surface ofthe ear (i.e., the side of the ear facing toward the patient). Inanother embodiment, the sensor is externally located on the skin of thepatient's head below the mastoid. In still further embodiments, thesensor can be positioned at a different location, and can be carried bythe earpiece(s), the neckpiece, and/or another portion of the system.

The electrical therapy signal can be applied to just a single ear, or toboth ears. When therapy is applied to both ears, the signal can be thesame for both, or at least one signal delivery parameter can differ fora signal applied to the right ear, as compared to a signal applied tothe left ear. The signal(s) can be applied simultaneously orsequentially to each ear. In some embodiments, by using one or bothears, the system can exploit the known difference in left versus rightvagus nerves as principally an inflow or outflow system of the NTS(nucleus tractus solitarius), respectively. Afferent fibers, accessiblein the tragal somatic representation of the vagus as well as sympatheticafferent neural inflows, will potentially enable the therapy signals inaccordance with the present technology to impact visceral sensory signalintegration at higher CNS (central nervous system) structures, includingthe NTS, RVLN (rostroventrolateral reticular nucleus), trigeminalnucleus, locus cerelous, parabrachial nucleus, hypothalamus, subsets ofthe thalamus, and/or cortical structures related to autonomicfunctioning and/or the dorsal motor nucleus.

The therapy signal can include waveforms other than that shown in FIG.12, e.g., a triangular waveform or a sinusoidal waveform. The therapysignal can be applied continuously (e.g., a 100% duty cycle), or inaccordance with a lower duty cycle, e.g., a 50% duty cycle or other dutycycle. The signal can vary, as described above. For example, the signalcan vary in an irregular, non-periodic manner, e.g., with bi-phasicpulses having a total duration of 50 us repeated randomly at from onemicrosecond to 100 microsecond intervals. In another embodiment, theirregular waveform can be characterized by the average number of zerocrossing (as defined by a change in polarity) of the signal. Forexample, the average number of zero crossings for any given second ofthe stimulation signal is 40,000 for a 20 kHz signal with bi-phasicrectangular pulses. The signal can also be applied either simultaneouslyor alternatingly to other peripheral nerves to further enhance thetherapeutic effect.

As discussed above, the patient and/or practitioner can modifytherapeutic doses of stimulation through a software application (an“app”) for a mobile electronic device (such as an iPhone or anAndroid-based mobile device) based on clinician guidelines and patients'adherence to the app. In other embodiments, the system can includeverbal response options to provide patients with verbal statements aboutthe status of the therapy, feedback, and/or instructions; the ability tomodulate the maximum amplitude (and/or other parameters) of the therapyfor the user based on conditioning and/or other sensor responses;monitoring the count of the therapy doses by the app (and/or systemhardware); and/or enable the patient to purchase a therapy session usingthe app or a companion device; enable clinicians to monitor thepatients' conditions and responses to therapy over the internet; and/orallowing clinicians to change the parameters of the therapy viainternet-enabled communications.

Representative targets for the electrical therapy signal, in addition toor lieu of the concha, include the antihelix, tragus, antitragus, helix,scapha, triangular fossa, lobule, and/or a lateral surface of the ear(i.e., the side of the ear facing the patient), although it is expectedthat stimulation provided to the concha will produce superior results.

As described above, some techniques in accordance with the presenttechnology include coordinating the delivery of the therapy signal withthe patient's respiratory cycles. Accordingly, the system can include arespiratory sensor that monitors the patient's respiratory exhalationand (a) activates the stimulator approximately at the start of eachexhalation phase and (b) deactivates the stimulator approximately at theend of the each exhalation phase. The respiratory sensor can use motionor acoustic monitoring technology to identify the start and end of eachexhalation phase. The respiratory sensor can be integrated in a chest orstomach belt, or integrated into a face mask. Further, the respiratorysensor can be have a band-aid-type form factor, and can placed on thepatient's neck. In another configuration, the respiratory sensor caninclude an optical sensor, such as a photoplethysmogram (PPG) sensorthat is integrated with the earpiece.

As discussed above, the disclosed electrical therapy can be appliedalone or in combination with a pharmacological/biologic treatment. Inother embodiments, the therapy can be combined with still furthertherapy types (e.g., electrical stimulation at another location of thebody) in addition to or in lieu of a combination withpharmacological/biologic treatments.

Elements of the present disclosure described under a particular Headingmay be combined with elements described under other Headings in any of avariety of suitable manners. To the extent any materials disclosedherein by reference conflict with the present disclosure, the presentdisclosure controls.

The following examples provide further representative embodiments of thepresent technology.

EXAMPLES

1. A system for treating a patient, comprising:

-   -   a signal generator having instructions to generate an electrical        therapy signal, at least a portion of the electrical therapy        signal having:        -   a frequency at or above the patient's auditory frequency            limit;        -   an amplitude in an amplitude range from about 0.1 mA to            about 10 mA; and        -   a pulse width in a pulse width range from 5 microseconds to            30 microseconds; and    -   at least one earpiece having a contoured outer surface shaped to        fit against the skin of the patient's external ear, external ear        canal, or both, the at least one earpiece carrying at least two        transcutaneous electrodes positioned to be in electrical        communication with an auricular nerve of the patient.

2. The system of example 1 wherein the frequency of the electricaltherapy signal is in a frequency range of about 15 kHz to about 50 kHz.

3. The system of example 1 wherein the electrical therapy signal is anon-paresthesia-generating electrical therapy signal.

4. The system of example 1 wherein the electrical therapy signal is anon-sensory response electrical therapy signal.

5. The system of example 1 wherein the at least two transcutaneouselectrodes include a conductive polymer outer surface.

6. The system of example 1 wherein the signal generator includes aneckpiece positionable to be supported by the patient around thepatient's neck, and wherein the system further comprises an earpiecelink coupled between the neckpiece and the at least one earpiece.

7. The system of example 6 wherein the earpiece link includes at leastone elongated conductor.

8. The system of example 6 wherein the at least one earpiece isremovable from the earpiece link.

9. The system of example 6 wherein the earpiece link and the signalgenerator are contained in a unitary housing.

10. The system of example 1 wherein the at least one earpiece includes afirst earpiece shaped to fit the patient's right ear and a secondearpiece shaped to fit the patient's left ear.

11. The system of example 1 wherein the at least one earpiece is customfit to the patient's ear.

12. The system of example 1, further comprising an audible feedbackdevice coupled to the at least one earpiece to generate a feedbacksignal in the patient's audible frequency range.

13. The system of example 12 wherein a frequency of the feedback signalis patient-specific.

14. The system of example 1, further comprising a proximity sensorpositioned to detect a location of the at least one of the electrodesrelative to the patient's skin.

15. The system of example 1, further comprising an external controllerconfigured to be in wireless communication with the signal generator.

16. The system of example 15 wherein the external controller includes amobile device having an application for controlling the signalgenerator.

17. A system for treating a patient, comprising:

-   -   a signal generator having instructions to generate an electrical        therapy signal, at least a portion of the electrical therapy        signal having:        -   an average frequency at or above the patient's auditory            frequency limit, wherein the average frequency is the            inverse of the average period of the signal over multiple            periods, and wherein individual periods are the sum of a            first pulse width of a first pulse at a first polarity,            neighboring, second pulse at a second polarity opposite the            first polarity, an interphase period between the first and            second pulses, and an interpulse period between the second            pulse and the next pulse of the first polarity;        -   an amplitude in an amplitude range from 0.1 mA to 10 mA; and        -   a pulse width in a pulse width range from 5 microseconds to            30 microseconds; and    -   at least one earpiece having a contoured outer surface shaped to        fit against the skin of the patient's external ear, external ear        canal, or both, the at least one earpiece carrying at least two        transcutaneous electrodes positioned to be in electrical        communication with an auricular nerve of then patient.

18. The system of example 17 wherein the frequency of the electricaltherapy signal is in a frequency range of about 15 kHz to about 50 kHz.

19. The system of example 17 wherein the electrical therapy signal is anon-paresthesia-generating electrical therapy signal.

20. The system of example 17 wherein the electrical therapy signal is anon-sensory response electrical therapy signal.

21. The system of example 17 wherein the signal generator includes aneckpiece positionable to be supported by the patient around thepatient's neck, and wherein the system further comprises an earpiecelink coupled between the neckpiece and the at least one earpiece.

22. The system of example 21 wherein the earpiece link includes at leastone elongated conductor.

23. The system of example 21 wherein the at least one earpiece isremovable from the earpiece link.

24. A method for treating a patient, comprising:

-   -   applying an electrical therapy signal to an auricular nerve of        the patient via a plurality of transcutaneous electrodes carried        by an earpiece positioned against the skin of the patient's        external ear, external ear canal, or both; and    -   wherein at least a portion of the electrical therapy signal has:        -   a frequency at or above the patient's auditory frequency            limit;        -   an amplitude in an amplitude range from 0.1 mA to 10 mA; and        -   a pulse width in a pulse width range from 5 microseconds to            30 microseconds.

25. The method of example 24 wherein the electrical therapy signal doesnot generate paresthesia in the patient.

26. The method of example 24 wherein the electrical therapy signal doesnot generate a patient-detectable sensory response.

27. The method of example 24 wherein the frequency is in a frequencyrange from 15 kHz to 50 kHz.

28. The method of example 24 wherein applying the electrical therapysignal causes the auricular branch of the patient's vagal nerve togenerate an afferent response.

29. The method of example 24 wherein applying an electrical therapysignal includes applying the electrical therapy signal to only one ofthe patient's ears.

30. The method of example 24 wherein applying an electrical therapysignal includes applying at least one electrical therapy signal to bothof the patient's ears.

31. The method of example 30 wherein the same electrical therapy signalis applied to both ears.

32. The method of example 30 wherein an electrical therapy signalapplied to one of the patient's ears has a parameter value differentthan the corresponding parameter value of an electrical therapy signalapplied to the other of the patient's ears.

33. The method of example 30 wherein one or more electrical signals areapplied to both ears simultaneously.

34. The method of example 30 wherein one or more electrical signals areapplied to both ears sequentially.

35. The method of example 24 wherein applying the electrical therapysignal causes improved connectivity between at least two regions of thepatient's brain.

36. The method of example 24 wherein applying the electrical signalincludes increasing the amplitude of the signal over multiple steps froma first value to a second value.

37. The method of example 24 wherein applying the electrical signalincludes applying the electrical signal to address an inflammatorycondition of the patient.

38. The method of example 37 wherein the inflammatory condition includesrheumatoid arthritis.

39. The method of example 24 wherein applying the electrical signalincludes applying the electrical signal to address a sleep disorder ofthe patient.

40. The method of example 24 wherein applying the electrical signalincludes applying the electrical signal to address a neurologicalindication of the patient.

41. The method of example 24 wherein the neurological indication includepost-partum depression.

42. The method of example 24 wherein applying the electrical signalincludes applying the electrical signal to enhance the patient'sfunctioning.

43. The method of example 42 wherein the patient's functioning includesthe patient's memory.

44. The method of example 24 wherein applying the electrical signalincludes applying the electrical signal to address a headache and/ormigraine indication of the patient.

45. The method of example 24 wherein applying the electrical signal isperformed as part of a treatment regimen that also includes apharmacological treatment of the patient.

46. The method of example 45 wherein the pharmacological treatment ofthe patient includes treatment with DMARD class of pharmaceuticalcompound.

47. The method of example 24 wherein applying the electrical signalincludes applying the electrical signal over the course of at most twosessions per day.

48. The method of example 47 wherein an individual session lasts forbetween two seconds and 60 minutes.

49. The method of example 47 wherein an individual session lasts forbetween two seconds and 30 minutes.

50. The method of example 47 wherein an individual session lasts for 15minutes.

51. The method of example 47, further comprising tracking a number ofsessions.

52. The method of example 24 wherein the auricular nerve includes anauricular branch of the patient's vagal nerve.

53. A method for making a patient treatment device, comprising:

-   -   programming a signal generator to produce an electrical therapy        signal, at least a portion of the electrical therapy signal        having:        -   a frequency at or above the patient's auditory threshold;        -   an amplitude in an amplitude range from about 0.1 mA to            about 10 mA; and        -   a pulse width in a pulse width range from about 5            microseconds to about 30 microseconds; and    -   coupling the signal generator to at least one earpiece having a        contoured outer surface shaped to fit against the skin of the        patient's external ear, external ear canal, or both, the at        least one earpiece carrying at least two transcutaneous        electrodes positioned to be in electrical communication with an        auricular nerve of the patient.

54. The method of example 53 wherein the frequency is in a frequencyrange from about 15 kHz to about 50 kHz.

55. The method of example 53, further comprising forming the contouredouter surface of the at least one earpiece based at least in part on apatient-specific physiologic feature of the patient's ear.

56. The method of example 53, further comprising forming at least partof the at least one earpiece using an additive manufacturing technique.

We claim:
 1. A system for delivering electrical signals to a personhaving rheumatoid arthritis, comprising: a signal generator havinginstructions to generate an electrical signal to address the person'srheumatoid arthritis, at least a portion of the electrical signalhaving: a frequency at or above the person's auditory frequency limit,wherein the frequency is in a frequency range of about 15 kHz to about50 kHz; an amplitude in an amplitude range from about 0.1 mA to about 10mA; and a pulse width in a pulse width range from about 5 microsecondsto about 30 microseconds; and at least one earpiece having a contouredouter surface shaped to fit against the skin of the person's externalear, external ear canal, or both, the at least one earpiece carrying atleast two transcutaneous electrodes coupled to the signal generator andpositioned to be in electrical communication with an auricular nerve ofthe person.
 2. The system of claim 1 wherein the electrical signal is anon-paresthesia-generating electrical signal or a non-sensory responseelectrical signal.
 3. The system of claim 1 wherein the at least twotranscutaneous electrodes include a conductive polymer outer surface. 4.The system of claim 1 wherein the signal generator includes a neckpiecepositionable to be supported by the person around the person's neck, andwherein the system further comprises an earpiece link coupled betweenthe neckpiece and the at least one earpiece.
 5. The system of claim 4wherein the earpiece link and the signal generator are contained in aunitary housing.
 6. The system of claim 1 wherein the at least oneearpiece includes a first earpiece shaped to fit the person's right earand a second earpiece shaped to fit the person's left ear.
 7. The systemof claim 1 wherein the at least one earpiece is custom fit to theperson's ear.
 8. The system of claim 1, further comprising a proximitysensor positioned to detect a location of the at least one of the atleast two transcutaneous electrodes relative to the person's skin. 9.The system of claim 1, further comprising an external controllerconfigured to be in wireless communication with the signal generator,wherein the external controller includes a mobile device having anapplication for controlling the signal generator.
 10. A system fordelivering electrical signals to a person having rheumatoid arthritis,comprising: a signal generator having instructions to generate anelectrical signal to address the person's rheumatoid arthritis, at leasta portion of the electrical signal having: an average frequency at orabove the person's auditory frequency limit, wherein the averagefrequency is the range of about 15 kHz to about 50 kHz, wherein theaverage frequency is the inverse of the average period of the signalover multiple periods, and wherein individual periods are the sum of afirst pulse width of a first pulse at a first polarity, a neighboring,second pulse at a second polarity opposite the first polarity, aninterphase period between the first and second pulses, and an interpulseperiod between the second pulse and the next pulse of the firstpolarity; an amplitude in an amplitude range from about 0.1 mA to about10 mA; and a pulse width in a pulse width range from about 5microseconds to about 30 microseconds; and at least one earpiece havinga contoured outer surface shaped to fit against the skin of the person'sexternal ear, external ear canal, or both, the at least one earpiececarrying at least two transcutaneous electrodes coupled to the signalgenerator and positioned to be in electrical communication with anauricular nerve of the person.
 11. The system of claim 10 wherein theelectrical signal is a non-paresthesia-generating electrical signal. 12.The system of claim 10 wherein the electrical signal is a non-sensoryresponse electrical signal.
 13. The system of claim 10 wherein thesignal generator includes a neckpiece positionable to be supported bythe person around the person's neck, and wherein the system furthercomprises an earpiece link coupled between the neckpiece and the atleast one earpiece.
 14. The system of claim 13 wherein the earpiece linkincludes at least one elongated conductor.
 15. The system of claim 13wherein the at least one earpiece is removable from the earpiece link.16. The system of claim 10 wherein the interphase period is within arange from about 1 microsecond to about 10 microseconds.
 17. The systemof claim 10 wherein the interpulse period is within a range from about 1microsecond to about 10 microseconds.
 18. A method for delivering anelectrical signal to a person having rheumatoid arthritis, comprising:applying the electrical signal to an auricular nerve of the person toaddress the person's rheumatoid arthritis, wherein the electrical signalis applied via a plurality of transcutaneous electrodes carried by anearpiece positioned against the skin of the person's external ear,external ear canal, or both; and wherein at least a portion of theelectrical signal has: a frequency at or above the person's auditoryfrequency limit, wherein the frequency is in a frequency range fromabout 15 kHz to about 50 kHz; an amplitude in an amplitude range fromabout 0.1 mA to about 10 mA; and a pulse width in a pulse width rangefrom about 5 microseconds to about 30 microseconds.
 19. The method ofclaim 18 wherein the electrical signal does not generate paresthesia inthe person or does not generate a person-detectable sensory response.20. The method of claim 18 wherein applying the electrical signal causesthe auricular branch of the person's vagal nerve to generate an afferentresponse.
 21. The method of claim 18 wherein applying the electricalsignal includes applying the electrical signal to only one of theperson's ears.
 22. The method of claim 18 wherein applying theelectrical signal includes applying at least one electrical signal toboth of the person's ears.
 23. The method of claim 22 wherein the sameelectrical therapy signal is applied to both ears, and wherein (1) oneor more electrical signals are applied to both ears simultaneously or(2) one or more electrical signals are applied to both earssequentially.
 24. The method of claim 22 wherein applying the at leastone electrical signal includes applying a first electrical signal to oneof the patient's ears and a second electrical signal to the other of thepatient's ears, the first electrical signal differing from the secondelectrical signal with respect to one or more of frequency or amplitude.25. The method of claim 18 wherein applying the electrical signalincludes increasing the amplitude of the electrical signal over multiplesteps from a first value to a second value.
 26. The method of claim 18wherein applying the electrical signal is performed as part of atreatment regimen that also includes a pharmacological treatment of theperson.
 27. The method of claim 26 wherein the pharmacological treatmentincludes treatment with a DMARD class of pharmaceutical compound.